NOMNC INSTRUCTIONS

September 2020

Kepro

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• Kepro is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for 29 states

• Kepro is a government contractor for the Centers for Medicare & Medicaid Services (CMS)

• One of the responsibilities of the BFCC-QIO is to review hospital discharge and skilled service termination appeals

NOMNC Delivery

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• A Medicare provider or health plan must give a completed copy of the Notice of Medicare Non-Coverage (NOMNC) to Medicare beneficiaries who are receiving covered skilled nursing (including physical therapy), home health, outpatient rehabilitation, or hospice services

• The NOMNC must be given when the last skilled service is to be discontinued

• The NOMNC must be delivered at least two calendar days before Medicare-covered services end (Effective Date) or the second to the last day of service if care is not being provided daily

NOMNC Delivery (cont.)

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• The two-day advance requirement is two calendar days, not 48 hours o For example, the notice may be given at 3 pm on a Wednesday with the

effective date being Friday at noon

• The NOMNC is required even if the beneficiary agrees that services should end

• The NOMNC must be signed and dated by the Medicare beneficiary

• The beneficiary is not signing that he/she agrees with the notice, but rather he/she has received it

Beneficiary Representative

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• If the beneficiary is not competent (cannot make decisions for him/herself), then the notice must be delivered to his/her representative

• Typically a representative would be someone who has legal responsibility to make decision such as consent to treatment; however, each state has different definitions as to the representative

• It should be noted that states can allow non-family members to activate an appeal process. Healthcare providers should be knowledgeable about their state’s requirements for representative

Delivery to the Beneficiary Representative

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• Providers are required to have a procedure in place to address when the beneficiary is not competent, and the provider cannot get the representative’s signature in person

• The provider should call the representative on the phone to advise him or her when the services will no longer be covered

• The date of this telephone call is the delivery date of the notice and must be two calendar days prior to the effective date.

Delivery to the Beneficiary Representative (cont.)

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• The information provided during the representative phone call should include the following:o The beneficiary’s last day of covered services and the date when the

beneficiary’s financial liability is expected to begino The beneficiary’s right to appeal a coverage termination decisiono A description of how to request an appeal by a BFCC-QIOo The deadline to request a review as well as what to do if the deadline is

missedo The telephone number of the BFCC-QIO to request the appeal

• The above detailed information should be noted on the NOMNC in the “Optional: Additional Information” section found on page 2

Delivery to the Beneficiary Representative (cont.)

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• The telephone call with the beneficiary’s representative must be confirmed by mailing a copy of the completed NOMNC to the representative on the same day as the phone call

• If you can’t reach the representative by phone, send the notice by certified mail, return receipt requested

• The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date of delivery

• A dated copy of the notice must be placed in the beneficiary’s medical file

• If the post office returns the notice with no indication of a refusal date, liability starts the second day after the provider’s mailing date

Completing the NOMNC

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• The NOMNC cannot be more than two pages. It can be two sides of one page or one side of two separate pages

• By OMB guidance, the NOMNC cannot extend beyond two pages –it could become an invalid notice if it did

• Any entries on the form must be 12-point font, including handwritten entries (which must be legible)

Completing the NOMNC: Organization Contact Information

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• Providers may include their organization’s logo and contact information on the top of the NOMNC. When adding this information, be sure that no text moves from page 1 to page 2

• Logos, address headers, etc. should be reduced in size to be sure that no text moves from page 1 to page 2

• The provider’s name, address, and telephone number must appear above the title of the form

Completing the NOMNC: Beneficiary Information

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• Providers may fill in the beneficiary’s unique medical record or other identification number for the member number

• The Health Insurance Claim Number (HIC), also known as the Medicare number, must not be used

• Providers may include information in the “Optional: Additional Information” section relevant to the beneficiary’s situation

Completing the NOMNC (cont.)

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• In the first sentence, “THE EFFECTIVE DATE YOUR {INSERT TYPE} SERVICES WILL END” o Insert the effective date (which is the date the services will end) and the

type of services (home health, skilled nursing, comprehensive outpatient rehab services, or hospice)

• In bullet 4 under the sub-heading “HOW TO ASK FOR AN IMMEDIATE APPEAL” o Insert the name and telephone numbers (including TTY) of Kepro, which

may be found at www.keproqio.com

Completing the NOMNC: Medicare Advantage Plan Information

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• On the Signature page: “Plan contact information (for Health Plans enrollees only)”: o The plan’s name and contact information must be displayed here for the

beneficiary’s use in case an expedited appeal is requested or in the event the beneficiary or Kepro needs this information

Additional Information

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• Under “Optional: Additional information”o This section provides space for additional pertinent information that may

be useful to the beneficiaryo This area may not be used to take the place of the Detailed Explanation of

Non-Coverage, even if facts pertinent to the termination decision are provided

o If the Medicare beneficiary refuses to sign the document, this section can be used to annotate their refusal

Signature and Date

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• On the Signature line: o The beneficiary or his/her

representative must sign this line

• For the Date: o The beneficiary or his/her

representative must fill in the date that he or she signs the document

o If the document is delivered, but the beneficiary or the representative refuses to sign on the delivery date, then note on the medical record that the form was delivered

Invalid Notices

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• Common issues that make the NOMNC invalido The name of the Medicare beneficiary is not written or typed in the

designated area on the formo There is no OMB approval number or CMS form numbero Outdated or expired notice is usedo The form is not signed, and there is no documentation of

verbal/telephone notification on the NOMNC or within the medical record

Invalid Notices (cont.)

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• Common issues that make the NOMNC invalido The signature can’t be read, and there is no documentation in the

beneficiary’s medical file on the delivery of the noticeo Documentation of the verbal/or telephone notice is lackingo The notice was not delivered within the required time frameo The future Effective Date is greater than 3 days

Additional Information

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Publication No. R146810-111-9/2020. This material wasprepared by KEPRO, a Medicare Quality ImprovementOrganization under contract with the Centers for Medicare &Medicaid Services (CMS), an agency of the U.S. Department ofHealth and Human Services. The contents presented do notnecessarily reflect CMS policy.

For more information about how to fill out the NOMNC or to download the notice, visit the CMS Beneficiary Notices Initiative website at www.cms.gov/bni.